Ratings are not given for this type of inspection.

At this inspection, we found that:

• Ward managers for Wortham (locked rehab) and Wimpole (low secure) and the senior management team were unable to access figures for mandatory training, supervision or appraisal completion. It was unclear how staff performance was being monitored and any issues addressed.
• Senior management and the ward managers across the hospital met each morning to review incidents and staffing levels for the previous 24 hours. Minutes from these meetings lacked detail and did not reflect the discussion regarding the two serious incidents that led to the CQC unannounced inspection.
• Environmental ligature risk audits for Wimpole and Wortham wards did not contain details of all ligature risks present within the ward and treatment environments.
• Patient’s care plans and risk assessments were not linked to the environmental ligature risk audits to mitigate and manage individual risks.
• Blind spots and poor lines of sight for monitoring patients remained on the wards. This issue was identified in the 2016 inspection, but had not been resolved in its entirety.
• We identified poor cleanliness on both wards, particularly in toilets, bathrooms and the rehabilitation kitchen on Wortham ward. This increased infection control risks for patients and staff.
• We found examples of contraband and restricted items on Wortham ward such as cigarettes butts. It was unclear how regularly staff completed patient and property searches in line with the provider’s prohibited items policy and environmental ligature risk audits action points.
• Staff and ward managers reported concerns in relation to the varying quality and level of detail given at shift handovers, particularly where shifts contained agency staff and staff unfamiliar with the patients and ward environment.
• Records for patients on enhanced levels of observation contained gaps and inconsistencies. Staff were not adhering to the provider’s observation policy.
• We identified a lack of appropriate professional boundaries between staff and patients on Wimpole ward.

Patient that we spoke with during our inspection on 09 July 2013 were generally positive about the care and support they received. They made comments such as; “The staff are helpful and help me plan my week.” Patients that we met told us that they were able to discuss their concerns with members of the care staff.

Care and support was being regularly reviewed to ensure that patients’ needs were being met. There was evidence of patient’s involvement in the planning of their care and support.

Dietary and nutritional needs were being met and patients chose from menus through the hospital catering services. Some patients were involved in self-catering and they were able to make individual choices and shop at local supermarkets with staff assistance.

There were regular ongoing training sessions in place to ensure that staff could safely deliver care and support to patients. However, improvements were needed to staff supervision arrangements to ensure that they received it at regular intervals

There had been concerns raised regarding staffing levels. Patients that we spoke with told us that staff shortages had meant that some trips to the local community had been cancelled. Staff we spoke with told us that staff shortages had prevented them from taking breaks and impacted on support that patients received.

There were quality assurance processes in place and patients were able to raise concerns and issues via the regular ‘Patients Council’ meetings.

During our inspection on 30 August 2012 we visited Wimpole Ward, one of the bungalows where people lived and The Skills Centre. People told us that they felt involved with the planning and reviewing of their care. One person told us that, "Staff will always talk with me when I need to talk”. Two people told us they were ‘Patient Representatives’ and attended meetings with managers of the service to represent patients’ views. There were regular ward meetings where people could discuss day to day issues and concerns. Staff spoken with during our visit informed us that people were fully involved in making decisions and that where possible, their concerns were acted upon. People using the service told us that there were activities available and that they particularly enjoyed going to the gym with staff.

Staff spoken with confirmed that they have received training in safeguarding people from harm or abuse. They were aware of the different types of abuse that would constitute a safeguarding referral having to be made and were aware of whom to report safeguarding concerns to.

The provider had robust recruitment and selection policies and procedures to ensure that staff they employed were fit to work with vulnerable people. Staff received ongoing training, appraisal and supervision throughout the year to ensure their safe practice

We spoke with eight people using the services on both Clopton and Wimpole wards. They told us that much of their day was spent, “Just hanging around with little in the way of positive, constructive activities”. Some people told us they were bored and felt under- stimulated. People said that they did not feel they were being consulted about service changes that would affect their care and treatment.

Some people who use services were involved in a peaceful protest about their care as they felt they were not being listened to and changes were not taking place. They felt the actions taken by the hospital after the protest were, "Unfair."

We rated Kneesworth House Hospital as good because:

• Staff completed detailed risk assessments using recognised tools that included comprehensive risk management plans. Staff updated individual risk assessments following incidents. Staff knew what incidents should be reported, incidents were reviewed and feedback distributed to staff via a ‘lessons learnt’ bulletin and discussion in meetings. We identified positive reductions in restrictive practices linked to individualised risk assessments on the medium secure wards. Rehabilitation wards reported low levels of restraint and seclusion over the past nine months.
• Overall mandatory training compliance for staff was 84%. Safeguarding adult training compliance was 98% and for safeguarding children was 96%. They received supervision in line with the provider’s policy, attending both 1:1 supervision and group reflective practice sessions. Compliance ranged between 72% and 100%. Staff received a thorough induction programme with support workers training to care certificate standards. Staff accessed regular reflective practice sessions.
• The provider had estimated staffing levels on the wards and numbers and mix of staff was adjusted to take into account of patient need and safety. Ward managers block booked agency staff to provide continuity of care for patients.
• On the rehabilitation and acute wards the provider had mitigated risks posed by obstructed lines of sight by the use of convex mirrors and closed circuit television. The provider had refurbished the bathrooms and wash hand basins in bedrooms on the acute ward with anti-ligature fixtures and fittings. The provider had improved infection control by removing carpeting from the majority of the wards and replacing with laminate flooring in line with the 2016 inspection report action plan. Housekeeping staff kept most ward areas visibly clean.
• Patients accessed regular physical health care monitoring; a GP visited the site twice a week, with practice nurses based on site. Care records showed that staff monitored patients’ physical health needs throughout their admission.
• Psychology staff delivered specialist treatment programmes, working with models recognised for use in secure and rehabilitation services. Occupational therapists provided vocational rehabilitation programmes and encouraged patients to access opportunities to aid reintegration with the local community.
• Secure wards held regular multi-disciplinary team meetings and encouraged patient attendance to contribute to their care and treatment programmes. Patient records contained detailed information relating to leave entitlement and outcomes. Where patients did not have authorised leave, staff tailored therapeutic activities for the ward environment. Staff regularly discussed discharge planning as part of multi-disciplinary and professionals meetings. Discharge planning commenced at the point of admission on to rehabilitation wards and staff on all wards focussed on treatment, recovery and reintegration back into the community.
• We observed many caring and compassionate interactions between staff and patients. Patients told us that staff were caring and approachable, and most said they felt safe on the wards. Patients gave examples of where staff had gone above and beyond to offer them support for example staying late to facilitate family visits. Patients were involved in developing care plan goals, and completed a document that included their goals, strengths and how they liked staff to support them.
• The wards ran a variety of activities including at weekends for patients to attend. Patients had regular visits to community services and could access local shops and gym with authorised leave.
• The provider had a clear complaints policy and this included sending update letters to complainants. Patients felt their complaints were answered and action taken as a result.

However:

• All secure wards contained blind spots and poor lines of sight. Environmental ligature risks were present on all secure and rehabilitation wards; the corresponding audit tool was cumbersome and did not assist staff to link environmental risks to patient’s individual risk assessments and care plans. The quality of patient care plans varied across the secure wards. Agency staff told inspectors they could not access electronic patient records relating to risk information.
• Shift handover meetings on secure wards did not discuss patient observation levels or associated clinical risks in detail. Mirrors above the wash hand basin in two bathrooms on the acute ward had sharp corners. We identified safety concerns in seclusion rooms. Seclusion paperwork on secure wards contained gaps in recording and non-compliance with the provider’s seclusion policy and the Mental Health Act Code of Practice. Provider supplied data showed 410 episodes of restraint across the wards for the six months prior to the inspection.
• Staff did not consistently complete ward security checks, and took personal belongings including contraband items through the secure reception areas and onto the wards. Staff reported delays in serious incident investigation outcomes and implementation of associated action plans for the acute and secure wards.
• Some treatment environments were tired and in need of refurbishment. Housekeeping staff did not consistently adhere to infection control practices, and staff did not consistently adhere to the provider’s dress code.
• On wards without emergency grab bags, staff stored emergency medicines in clinic room cupboards, this could result in staff confusion in an emergency. Some medication cards examined had authorisation signatures missing and examples of incorrect medication administration. National early warning score assessment paperwork did not include the corresponding chart to check scores against. There were episodes of missed nasogastric feeding on a secure ward.
• Wards had between eight percent and 35% staff vacancy rate, and a high use of agency staff. Patients reported cancellation in 1:1 sessions and activities due to staffing pressures. Some acute ward staff told us they regularly moved between wards to cover staffing shortages.Inspectors identified concerns in the management of staff breaks. Frequency of staff meetings varied across the wards.
• Inspectors identified some examples of punitive approaches used on the secure wards particularly in relation to Section 17 leave entitlement. Carers and family members of secure ward patients reported concerns about patient safety and the quality of communication with ward staff. Some patients on secure wards reported feeling unsafe, with a bullying culture between patients.Patients on the acute ward told us that the community meeting was being held too early in the morning and that it was often cancelled. Patients told us that actions arising from these community meetings were not carried out. The quality of patient community meeting minutes varied between wards. The provider did not have a staff or patient lead for equality and diversity. Their policy did not include how to manage staff receiving abuse due to protected characteristics such as race or gender. Some staff reported having been racially abused by patients and that the provider had not addressed this.